Financial Assistance Information 
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Effective January 1, 2016

In accordance with federal EMTALA regulations and state law, Touchette Regional Hospital will evaluate all emergency room patients for emergency medical conditions regardless of insurance coverage or the ability of patients to pay. Patients who have no insurance who are presenting for emrgent services will be screened for immediate (presumptive) eligibility and may be offered a Financial Application at time of service. If the patient is unable to accept an application at that time, an application will be mailed to the address on record for the patient. The completed application must be returned within 90 days of the service or inpatient discharge.

Patients who do not have medical coverage but request non-emergent hospital services at Touchette Regional Hospital will be reviewed for eligibility under the Hospital's Financial Assistance Policy either prior to the service being received or at the time of service. Determination will be based upon the following criteria:

" The patient is an established resident of the state of Illinois or has an order from an on-staff physician who is contracted with Touchette Regional Hospital " The patient falls under programs determined to be Presumptive " The patient has completed an application and qualifies based on family poverty levels for the patient's household.

The amount of Financial Assistance is granted upon the patient's overall financial situation and any rules and regulations set forth by the federal government or State of Illinois. If a submitted application is unclear or does not provide enough information for Touchette to make a decision for assistance, the patient will be asked to provide further documentation and services may be postponed. Completed applications for Financial Assistance will be reviewed and a decision made within no more than 5 business days.

Patients presenting for non-emergent services and who do not qualify for 100% financial assistance will be expected pay an estimated cost for the service or minimum deposit prior to receiving the non-emergent service payment in accordance with the Hospital Payment Policy. Estimates for services can be requested in accordance with our Pricing Transparency Policy.

Patients who have been approved for Financial Assistance will have to reapply each year. If a patient gets insurance after being approved for Financial Assistance, the patient's insurance will be billed for all eligible services and the patient will be taken off of the approval list for assistance beyond the date the insurance began.

Financial Applications offered by Touchette Regional Hospital will cover services billed by Touchette Regional Hospital. There may be physician fees associated with your visit and may not be eligible for Financial Assistance. When in question, the patient should ask his or her physician if they are covered under Touchette's Financial Assistance Policy. A list of providers is attached as an Addendum to the full policy, which can be found by visiting www.Touchette.org .

Patients who elect to enter our New Vision Program or patients who have been involved in an auto accident, Worker's Compensation, or other legal case for the visit will not be provided with Financial Assistance. Patients with legal cases that are dropped with no settlement or payment may apply for Financial Assistance for additional consideration.

Patients who have insurance but are left with a balance greater than $200 after insurance has paid (per the patient's Explanation of Benefits) may apply for Financial Assistance to help in covering the deductibles and/or copays. A completed application must be received within 90 days from patient's insurance payment. No patient will be billed more than amounts generally billed, which is a percentage of total charges.

Applications may be provided in person by the Patient Access Staff in the Outpatient Registration area, Emergency Department, or Physical Therapy at the Archview Medical Center. Applications may also be downloaded from our website at www.Touchette.org , emailed, faxed, or mailed to the patient upon request. Additional assistance, information, and applications can be requested by calling Patient Accounting at (618) 482-7128 or by emailing PatientAccounting@Touchette.org

Payment Policy Effective March 1, 2009 / Revised 2015

Outpatient Elective Services Patients presenting for these services will be responsible on the day of visit to pay either their insurance co-payment or the non-refundable hospital deposit as set out below if not qualified for 100% Financial Assistance. Whenever possible, patients will be pre-advised of their obligations prior to presenting.

Important: Any co-payment or non-refundable hospital deposit does not constitute payment in full. Final billing for the remainder costs will be mailed to each patient and/or the responsible party for payment. Outpatient Services may be postponed if the payment requirements cannot be met and are not identified as a stat order.

Unscheduled Ancillary Services: $15 per service Scheduled Recurring Services: $15 per service Pre-Surgery Ancillary Services: No Deposit Required

Scheduled Ancillary Services: Cardio / EKG $25 Cardio / Echo $150 Cardio / Stress $100

Radiology / X-Rays $30 Radiology / CT's $100 Radiology / Ultrasounds $40 Radiology / MRI's $450 Radiology / Mammograms $30

Surgery (as determined by your physician): Intensive $240 and Anesthesiologist $300 Moderate $120 and Anesthesiologist $200 Low $100 and Anesthesiologist $100 Very Low (Scopes) $75

Specialty Services: New Vision Program $2,500 Cosmetic Procedures 7% of Est Gross Charges

Emergency Department Services Services will be provided prior to request for payment. After services have been provided, patients may be requested to provide their co-pay or a deposit on the services rendered if they have been determine to not qualify for Financial Assistance. The patient may also be asked to set up a payment arrangement for a future date.

Emergency Room: $100 per visit



Billing & Collections Policy

Financial Applications

Health Plans Accepted

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